UNIVERSITY OF TROMSØ
Early sexual debut and
health outcome in
Norwegian men who have
sex with men (MSM)
An anonymous internet based cross-sectional survey through a chatroom targeted at men who have sex with men (MSM)
Med-3940, 5th year assignment
Daniel Guneriussen, mk-08
Supervisor: Elise Klouman, MD, PhD
Associate professor
Department of Community Medicine
[email protected]
University of Tromsø
Tromsø, May 2013
TABLE OF CONTENTS
1.0 Definitions……………………………………………………………………………….2
2.0 Abstract………………………………………………………………………………….3
3.0 Introduction……………………………………………………………………………..4
4.0 Methods………………………………………………………………………………….6
5.0 Results…………………………………………………………………………………....8
5.1 Characteristics of MSM respondents…………………………………………………..8
5.2 Sexual orientation and sexual debut………………………………………………….10
5.3 Education, income and employment………………………………………………….11
5.4 Sexual behaviour…………………………………..………………………………….12
5.5 Self-perceived health………………………………………………………………....14
5.6 HIV…………………………………………………………………………………...14
5.7 Alcohol………………………………………………………………………………..15
5.8 Drug use……………………………………………………………………………....17
6.0 Discussion………………………………………………………………………………19
7.0 References……………………………………………………………………………...23
Page 1 of 25
2.0 Definitions
MSM – men who have sex with men
NIPH – Norwegian institute of public health
MSIS – the Norwegian Surveillance System for Communicable Diseases
UAI – unprotected anal intercourse
AFAI – age at first anal intercourse
STI – sexual transmitted infections
Anonymous partner – a sex-partner witch an unknown identity (unknown name, face, meet in
a “dark room” etc.)
Casual partner – a sex-partner that the person doesn’t have a steady relationship with.
XTC – ecstasy
Poppers – Butyl or amyl nitrate. Liquid used for inhalation. Increases heart rate, dilate arteries
and causes drop in blood pressure. This produces a "rush" that can be enjoyable; some
experiences increased sexual desire. www.homohealth.org
Page 2 of 25
1.0 Abstract
Introduction: HIV incidence in MSM in Norway has increased since 2003. Several studies
find associations between sexual debut age, HIV, usage of drugs and alcohol as well as
increased amounts of emotional and physiological distress. The overall aim of this study was
to describe the sexual debut age among a convenience sample of Norwegian MSM taking part
in an internet survey, and examine possible associations between an early sexual debut (first
intercourse with another man before 14 years of age) and work; education and income; selfperceived-health; sexual identity and sexual risk behaviour; drugs and alcohol use; and selfreported HIV status.
Methods: A cross-sectional internet-based survey was done in 2007 among members of a
MSM-oriented Norwegian web-site. A self-administrated standardized questionnaire was
filled in anonymously and submitted in a questback format. Descriptive statistics are
presented and the strength of associations was measured by Pearsons’s chi-square test and
univariate logistic regression analysis.
Results: The survey had 2598 respondents (16-74 years range), 383 with an early debut (84
with no debut) and 2106 with a later debut. An early sexual debut was associated with: a low
education (OR=1,8 [1,2-2,8]); being unemployed/ retired/ social security taker (OR=1,7 [CI
1,2-2,4]); having >10 lifetime sex-partners OR=2,0 [1,5-2,6]; >500 lifetime sex-partners OR
= 2,1 [1,3-3,3]; unprotected anal intercourse with a casual partner OR=1,5 [CI 1,1-2,0]; poor
self-perceived health OR=2,6 [1,3-5,2]; taken a HIV test OR= 1,5 [1,2-2,0]; feeling drunk
alcohol intoxicated >7 times a month(OR=1,5 [1,1-1,9]; ever tried: marihuana/hash,
pharmaceuticals, ecstasy (XTC), LSD, GHB, cocaine, heroin, amphetamine,
methamphetamine, “poppers” and Viagra (lowest for poppers OR = 1,4 [1,1-1,8], highest for
methamphetamine OR = 4,4 [2,2-8,8]).
Conclusion: We found an association with numerous sexual partners and unprotected anal
intercourse (casual partner), but no associations to HIV status. An early debut was associated
with having taken a HIV test and a higher usage of drugs and alcohol among the early debut
group. Our results show associations between an early sexual debut and a poorer health
outcome, compared to a late debut.
Page 3 of 25
3.0 Introduction
There are few epidemiological studies on the sexual debut in men who have sex with men
(MSM) and health outcome, though there are many studies on MSM and risk taking
behaviour in general. To our knowledge, there are no Norwegian studies on this theme.
According to the Norwegian institute of public health’s (NIPH) repeated surveys on sexual
behaviour the median age for sexual debut in Norway has decreased for both genders over the
last decades (1, 2). The sexual debut seems to be lower in the MSM population then in the
general population, with a mean age of 15,7 years and median age 15 in 2002; compared to a
median of 17,5 years for men in the general population (2). Since the NIPH’s survey was
done in 2002 we have few up to date available studies on sexual debut and behaviour in
Norway. The measurement of prevalence and incidence of health conditions or infections in
subpopulations such as men who have sex with men (MSM) is hampered by the unknown size
and regional distribution of this "hidden" population (3). This is also the case for NIPH’s
sexual behaviour survey, which had a low number of attendances from the MSM population.
A Swedish study show that teenagers with a sexual debut at 14 year or younger tend to have
less positive school experiences, and more involvement in injuries and physical violence. The
girls were less physical active, and the boys more physical active; both genders perceived
their health as poorer than teenagers without intercourse experience (4). Gay juveniles are
shown to have a higher rate of emotional/psychological problems such as anxiety, depression,
and a higher risk of suicidal attempts. Those who have their sexual debut early, or recognize
their sexuality as homophile at a young age seems to be particular at risk (5, 6).
An American study report an association between drug use and unprotected anal intercourse
(UAI) (7). One study report an association between an early sexual debut and drug use,
especially with the use of marihuana (5), another report more drug related problems (8). An
early sexual debut is as well associated with smoking in MSM (9).
An Australian study finds a strong link between the age at first anal intercourse and infection
with HIV and sexual transmitted infections (STI’s), as well as tendencies to engage in high
risk sexual behaviour (10). An early debut seems to be associated with sexual risk behaviour,
such as numerous of sexual partners (11, 12), and unprotected anal intercourse at sexual debut
(13). Younger age at fist intercourse is associated with higher risk of STI’s compared to those
Page 4 of 25
who are older at the time of debut. The effect seems to be strongest in young adults and
juveniles, and diminishes with a higher current age (14). HIV-positive men were found to be
significantly younger on average when they first had anal intercourse compared with HIVnegative men (10). According to the Norwegian Surveillance System for Communicable
Diseases (MSIS) 76 new cases of HIV for the MSM group was reported in 2012, counting for
31,4 % of the total cases (table1). Even though there was a decrease of cases from 2011 to
2012 there has been an increase in HIV cases for the MSM group since the end of the 90’s,
especially from 2003 (15, 16). Internationally the importance of HIV preventive strategies for
the MSM group is emphasized, and evidence points to an increase in the HIV prevalence for
this group worldwide, as well in the western world (17).
Table 1 HIV infections in Norway by year of diagnosis and way of infection:
<03
03
04
Nosocomial
infection
Blood/
25
transplantation
Heterosexual
1120
153 161
Unknown
47
10
2
Maternal
29
5
1
Other
3
Needles
473
13
15
Cut- injury/
exposed to blood
Homosexual
836
57
71
Blood factor
21
Total:
2554
238 250
Table is generated from MSIS, www.fhi.no.
05
06
2
07
08
1
09
10
11
12
Total
3
1
134
3
5
165
7
6
141
8
9
184
5
4
20
1
7
13
56
90
219
277
26
157
4
1
155
2
4
142
6
7
12
171
8
4
1
11
11
10
11
77
93
88
85
97
76
248
299
284
258
268
242
2683
102
75
4
596
1
1627
21
5137
Most studies relate the MSM population to the growing HIV epidemic the last 30 years. It
might be just as important to enlighten other health problems existing in this population.
Several studies show that there is an association between an early sexual debut and
health/social problems compared to those with a later debut (4, 5, 8, 10-13). The overall aim
of this study is to describe the sexual debut age among a convenience sample of Norwegian
MSM taking part in an internet survey, and examine associations between an early sexual
debut and work, education and income; self-perceived health; sexual risk behaviour; selfreported HIV status; and drugs and alcohol use.
Page 5 of 25
Specific research questions are to:
-
describe the sexual debut age among MSM. How is the median sexual debut age in
this survey compared to the sexual debut age among heterosexual men and women in
the general population?
And examine if an early sexual debut is associated with:
-
sexual identity.
-
education, work and income.
-
sexual risk behaviour such as the lifetime number of sexual partners and unprotected
anal intercourse with casual or anonymous partners.
-
self-perceived health.
-
self-reported HIV prevalence, and HIV testing.
-
usage of alcohol and drugs.
4.0 Methods
Data for this study are obtained from the internet survey “Chatting on the internet, e-dating
and sexual risk behaviour among Norwegian men who have sex with men (MSM)” (18, 19).
About the survey
In October 2007 the Norwegian institute of Public Health in cooperation with Gay and
Lesbian Health Norway completed an anonymous internet based cross-sectional survey
through a chat-room targeted at men who have sex with men (MSM). The survey was
completed at www.gaysir.no, the single largest internet community for homosexuals in
Norway. At that moment Gaysir had about 31.000 member profiles and more than 50.000
visits each week. The site provides new items, a chat-community, a discussion forum, an
event calendar, links and other information. Participation was offered to logged-in members
from 1st to 19th of October 2007. The participants were fist guided to an introduction where
the aims and structure of the study were explained. Participation was voluntary and
anonymity was assured. Pilot testing was done with an offline and online testing of the
questionnaire by 15 MSM who provided a detailed feedback on the content, functionality and
the questionnaire layout. Data were collected using the online survey tool Questback,
harvested in Excel format and transformed to an SPSS file.
Page 6 of 25
The questionnaire had a total of 117 questions; it took about 45 minutes to finish. The
questions can be parted in 7 sub-groups: 1) Demographics and personal information, 2) sexual
behaviour, 3) Health and use of health services 4) dating and e-dating, 5) last e-date with sex,
6) drug and alcohol use 7) condom use and knowledge about STI’s. In this study we have not
used items from group 7.
Participants
The survey had a total of 2598 participants, 19 women were excluded, and 6 were excluded
because of age below 16 years; leaving a total of 2573 participants. 84 participants reported
that they never have had sexual relations to another man, thus leaving 2489 participants in the
main outcome variable, sexual debut age.
Sexual debut
A heterosexually debut means first time of vaginal intercourse between a man and a woman.
In a homosexual context a range of sexual events can be categorized as debut; the first sexual
encounter with another man regardless of the sexual act performed; the first sexual encounter
with another man who also identified himself as gay; the first act of penetrative intercourse
regardless of the partners sex; the first act of anal intercourse with a man; there are many
more examples (20, 21). In this study the question “how old were you the first time you had
sexual intercourse with another man” was used to specify the sexual debut age. The lowest
possible answer was 10 years, and the highest 50 years or more.
In this survey we study vulnerability in those with an early sexual debut compared to those of
a later sexual debut. An early sexual debut is in this survey defined as sexual relations to
another man before 14 years of age.
Data management and analysis
Statistical analyses are done with SPSS, version 19.
The main variable is sexual debut age, which is divided into two groups: early debut (debut
before 14 years) and later debut (14 years and later). Sexual debut age is described as median
age and rage of distribution. For sexual risk behaviour the variables used are lifetime numbers
of sexual partners and unprotected anal intercourse with anonymous or casual partner.
For self-reported HIV prevalence the variable “what was the result of your last HIV test” was
used. For alcohol consumption the question “how many times did you drink until you felt
Page 7 of 25
buzzed/intoxicated last month” was used. For drug use the variable “how many times have
you tried (drug) the last 12 months” was used.
Univariate frequency distributions in percent and means with standard deviations were used to
describe categorical and continuous variables, respectively. For the logistic regression we
used dichotomized variables, which are shown in tables. The strength of associations between
an early versus a later sexual debut and other health and social variables were measured with
Pearson’s chi-square test and univariate logistic regression analyses, where sexual debut age
was treated as the independent variable. P-values and odds-ratios (OR) with 95 % confidence
intervals are presented. A p-value ≤ 0.05 was considered significant. In the tables used in this
survey the group “total” includes those with no sexual debut (N=84).
Ethics
The study was approved by the Regional Committee for Medical and Health Research Ethics,
Southern Norway, and by the Norwegian Data Inspectorate.
5.0 Results
5.1 Characteristics of MSM respondents
Characteristics of MSM respondents are described in table 2. Of the total 2598 participants,
2573 was included for the general description statistics. The participants were between 16 and
74 years old, with a median age of 30 years. Mean age was 32,4 +SD 11,2. Almost all
participants lived in Norway, 75,8 % lived in a city or a greater city. 60 % lived in Eastern
Norway, most of them in Oslo. 93% of the population reports their cultural background as
Norwegian. About half of the population lives alone. 3,2 % are married, 6,5 % lives with a
partner and 15,4 % lives with roommate of the same gender. 5,2% has not completed more
than primary school, 56,8% has a higher education. About 70 % is employed, and a fifth of
the respondents are students. About 13 % had a high income, meaning more than 500 000
NOK a year. About 29 % had a low income, meaning less than 149 900 NOK.
Page 8 of 25
Table 2 Characteristics of MSM respondents in the internet-based cross-sectional study,
grouped by sexual debut:
Total*
N
Age:
16-25
26-35
36-45
46-55
55<
Total:
Place of residence:
Norway:
Abroad:
Total:
Regions:
Eastern Norway:
Southern Norway
Western Norway
Trøndelag
Northern Norway
Other:
Total:
Place of residence:
2
0*
Rural
Smaller town (200-2000 inhabitants)
Town (2001-20000 inhabitants)
City (20.001-100.000 inhabitants)
Greater City (over 100.000 inhabitants)
Total
Cultural background:
Norwegian
Western immigrant
Non-western immigrant
Other/missing:
Total:
Sexual orientation:
2
0*
Heterosexual
Homosexual
Bisexual/uncertain
Total:
*1 Total including those without a sexual debut.
*2 Missing.
1
%
Early
debut
N
%
Later
debut
N
%
849
797
578
255
94
2573
33,0
31,0
22,5
9,9
3,7
100,0
124
113
83
50
13
383
32,4
29,5
21,7
13,1
3,4
100,0
668
668
486
203
81
2106
31,7
31,7
23,1
9,6
3,8
100,0
2517
56
2573
97,8
2,2
100,0
375
8
383
97,9
2,1
100,0
2059
47
2106
97,8
2,2
100,0
1659
64
439
201
161
49
2573
64,5
2,5
17,1
7,8
6,3
1,9
100,0
230
9
68
31
33
12
383
60,1
2,3
17,8
8,1
8,6
3,1
100,0
1387
50
355
158
120
36
2106
65,9
2,4
16,9
7,5
5,7
1,7
100,0
(25)
98
162
339
493
1456
2573
(1,0)
3,8
6,3
13,2
19,2
56,6
100,0
17
28
41
89
201
376
4,5
7,4
10,9
23,7
53,5
100,0
76
123
277
387
1225
2088
3,6
5,9
13,3
18,5
58,7
100,0
2357
89
39
88
2573
91,5
3,5
1,5
3,5
100,0
357
9
6
7
379
94,2
2,4
1,6
1,8
100,0
1924
79
32
43
2078
92,6
3,8
1,5
2,1
100,0
(1)
12
1899
661
2573
(0,0)
0,5
73,8
25,7
100,0
0
287
96
383
0,0
74,9
25,1
100,0
7
1569
530
2106
0,3
74,5
25,2
100,0
Page 9 of 25
Table 2 Characteristics of MSM respondents in the internet-based cross-sectional study,
grouped by sexual debut (continued):
Total*
N
Education
2
0*
Primary/secondary school (≤9 years)
High school, practical classes
High school, theoretical classes
Major education, 2-4 years,
University, higher graduates
Others
Total:
Income:
2
0*
No income
0-49 900 NOK
50 000 – 149 900 NOK
150 000 – 199 900 NOK
200 000 – 249 000 NOK
250 000 – 299 000 NOK
300 000 – 500 000 NOK
>500 000 NOK
Total:
Employment:
2
0*
Paid work
Unemployed/searching for work
Student/pupil
Military service/civil service
Social security/retired
Sick leave
Staying at home
Other:
Total:
*1 Total including those without a sexual debut.
*2 Missing
1
%
Early
debut
N
%
Later
debut
N
%
(3)
133
494
450
951
510
32
2573
(0,1)
5,2
19,2
17,5
37,0
19,8
1,2
100,0
29
100
69
125
53
7
383
7,6
26,1
18,0
32,6
13,8
1,8
100,0
91
382
352
812
442
24
2103
4,3
18,2
16,7
38,6
21,0
1,1
100,0
(12)
159
230
356
130
205
262
882
337
2573
(0,5)
6,2
8,9
13,8
5,1
8,0
10,2
34,3
13,1
100,0
22
33
52
25
31
50
123
46
382
5,8
8,6
13,6
6,5
8,1
13,1
32,2
12,0
100,0
120
174
291
104
170
205
747
285
2096
5,7
8,3
13,9
5,0
8,1
9,8
35,6
13,6
100,0
(12)
1789
78
478
7
95
45
8
61
2573
(0,5)
69,5
3,0
18,6
0,3
3,7
1,7
0,3
2,4
100,0
266
13
51
0
22
12
2
16
382
69,6
3,4
13,4
0,0
5,8
3,1
0,5
4,2
100,0
1491
63
386
7
68
31
4
45
2095
71,2
3,0
18,4
0,3
3,2
1,5
0,2
2,1
100,0
5.2 Sexual orientation and sexual debut
15,4 % of those who are sexual active, has had sexual relations with another man before 14
years of age (figure 1). Three of four state their sexual orientation as homosexual, 12 men
(0,5%) define themselves as heterosexual, and approximately one forth define themselves as
bisexual. The bisexual group contains the following sub categories: homosexual partly
heterosexual; heterosexual partly homosexual; bisexual; and uncertain. Median age for sexual
relations with another man was 17 years (range 10 to more than 50 years), mean 17,9 years
+SD 5,7. 84 (3,3 %) reported never having had sex with another man. There were no
differences in sexual orientation between the sexual debut groups.
Page 10 of 25
Figure 1 Distribution of age at sexual debut with another man (in percent), in an internet
based study of MSM.
5.3 Education, income and employment
There seems to be a difference in education between the sexual debut groups, with a different
distribution in lower and higher education. The early debut group has an OR=1,8 [CI 1,2-2,8],
for low education defined as primary school or less (less than 9 years of school). OR for a
high educated is 0,6 [CI 0,5-0,7], defined as more than 2 years of education after high-school
(table 2, 3).
There was no statistical significant difference in income between the groups.
About 70% in both groups was employed. There is a larger proportion of students in the later
debut group, and a larger proportion of retired/unemployed/social security takers in the early
debut group. OR=1,7 [CI 1,2-2,4] for unemployed/social security/retired for the early debut
group (table 2, 3).
Page 11 of 25
Table 3 Associations between employment, education and sexual debut in MSM
respondents in the internet-based cross-sectional study, grouped by sexual debut:
Total
respondents
N (%)
Early
debut
N (%)
Highly educated
No
1109 (43,2)
205 (54,5)
Yes
1461 (56,8)
178(46,5)
Total
2570 (100,0)
383 (100,0)
Low education
No
2437 (94,8)
354 (92,4)
Yes
133 (5,2)
29 (7,6)
Total
2570 (100,0)
383 (100,0)
Unemployed/social
security/retired
No
2335 (91,2)
333 (87,2)
Yes
226 (8,8)
49 (12,8)
Total
2561 (100,0)
382 (100,0)
*1
Ref group for univariate logistic regression analyses.
Later debut*
1
P-value
OR [95 % CI]
<0,000
0,6 [0,5-0,7]
<0,007
1,8 [1,2-2,8]
<0,002
1,7 [1,2-2,4]
N (%)
849 (40,4)
1254 (59,6)
2103 (100,0)
2012 (95,2)
91 (4,3)
2103 (100,0)
1929 (92,1)
166 (7,9)
2095 (100,0)
5.4 Sexual behaviour
Sexual behaviour is described in table 4. 79,3% had 11 lifetime partners or more compared to
65,8% among those with a later debut. 7,6 % (early debut) and 3,8 % (later debut) had more
than 500 sexual partners. The early debut group reports a higher number of sexual partners.
OR for: 10< partners = 2,0 [1,5-2,6], 100< partners = 1,9 [1,5-2,5], 500< partners = 2,1 [1,33,3]. There was an association between an early debut and unprotected anal intercourse (UAI)
with a casual partner, OR= 1,5 [CI 1,1-2,0] and UAI after dating on the internet OR = 1,5 [CI
1,2-1,9]. No association was found when it comes to unprotected anal intercourse with an
anonymous partner and an early sexual debut.
Page 12 of 25
Table 4 Associations between sexual behaviour and sexual debut in MSM respondents in
an internet-based cross-sectional study, grouped by sexual debut:
Total
respondents
N (%)
Early
debut
N (%)
Later debut*
1
P-value
OR [95 % CI]
N (%)
N of lifetime sexual
partners:
2
2
*2
0*
88 (3,4)
1( 0,3)*
5( 0,2)
1
70(2,7)
7(1,8)
63(3,0)
2-5
340(13,2)
28(7,3)
311(14,8)
6-10
388(15,1)
44(11,5)
344(16,3)
11-50
888(34,5)
147(38,4)
741(35,2)
51-100
366(14,2)
55(14,4)
311(14,8)
101-500
324(12,6)
72(18,8)
242(12,0)
500<
109(4,2)
29(7,6)
79(3,8)
Total
2573(100,0)
383(100,0) 2106(100,0)
Lifetime sex-partners
<0,000
2,0 [1,5-2,6]
10<
No
798 (32,1)
79 (20,7)
718 (34,2)
Yes
1687 (67,9)
303 (79,3)
1383 (65,8)
Total
2485 (100,0)
382 (100,0) 2101 (100,0)
Lifetime sex-partners
<0,000
1,9 [1,5-2,5]
100<
No
2052 (82,6)
281 (73,6)
1770 (84,2)
Yes
433 (17,4)
101 (26,4)
331 (15,8)
Total
2485 (100,0)
382 (100,0) 2101 (100,0)
Lifetime sex-partners
<0,001
2,1 [1,3-3,3]
500<
No
2376 (95,6)
353 (92,4)
2022 (96,2)
Yes
109 (4,4)
29 (7,6)
79 (3,8)
Total
2485 (100,0)
382 (100,0) 2101 (100,0)
UAI with anonymous
0,1
1,4 [0,9-2,0]
*3
partner :
No
515 (68,8)
80 (63,0)
434 (69,9)
Yes
234 (31,2)
47 (37,0)
187 (30,1)
Total
1824 (100,0)
127 (100,0) 621 (100,0)
UAI with casual
<0,004
1,5 [1,1-2,0]
*3
partner :
No
1016 (64,6)
144 (56,7)
871 (66,1)
Yes
557 (35,4)
110 (43,3)
447 (33,9)
Total
1573 (100,0)
254 (100,0) 1318 (100,0)
UAI after dating on
<0,002
1,5 [1,2-1,9]
the internet
No
1506 (68,8)
208 (61,5)
1298 (70,2)
Yes
682 (31,2)
130 (38,5)
551 (29,8)
Total
2188 (100,0)
338 (100,0) 1849 (100,0)
*1
Ref group for univariate logistic regression analyses.
*2
A slightly different number (88) answered no lifetime partners, compared to the sexual debut question (84 with
no debut). They are still included in the analysis.
*3
Of those who had a casual/anonymous partner the last 6 months.
Page 13 of 25
5.5 Self-perceived health
Most of the participants in both groups see their health as good or very good (83,9 %).
Merging the categories into a good, a decent and a poor category there is a difference between
the early debut group and the later debut group (p=0,002). The early group has an increased
odds for poor self-perceived health, OR= 2,6 [CI 1,3-5,2] (table 5).
Table 5 Self-perceived health among MSM respondents in the internet-based crosssectional study, grouped by sexual debut:
Total
respondents
N (%)
Early
debut
N (%)
Self-perceived health:
Very good
931 (37,7)
134(35,3)
Good
1142(46,2)
166(46,7)
Decent/average
360(14,6)
68(17,9)
Poor
31(1,3)
10(2,6)
Very poor
7(0,3)
2(0,5)
Total
2471(100,0)
380(100,0)
*2
Poor self-perceived
health:
No
2433 (98,5)
368 (96,8)
Yes
38 (1,5)
12 (3,2)
Total
2471 (100,0)
380 (100,0)
*1
Ref group for univariate logistic regression analyses.
*2 Including poor and very poor.
Later debut*
1
P-value
OR [95 % CI]
<0,007
2,6 [1,3- 5,2]
N (%)
797(38,29
975(46,7)
291(13,9)
21(1,0)
5(0,2)
2089(100,0)
2063 (98,8)
26 (1,2)
2089 (100,0)
>100 life time sex partners was associated with a poor self-perceived health OR = 2,2 [1,14,5]. Feeling drunk more than 7 times a month was associated with a poor self-perceived
health OR 2,177 [1,1-4,3]. There was no association on the drugs included in this study and a
poor self-perceived health.
5.6 HIV
In total 71 participants report their HIV status as positive. About 30 % didn’t answer. Of those
responding 4,1 % reported themselves as HIV positive. 42 got the HIV diagnosis the last 12
months. In the early debut group 4,3% reported themselves as HIV positive, compared to
3,9% in the later debut group (p=0,8). 18,3 % of the HIV positives had their debut before 14
years of age (table 6).
Page 14 of 25
A total of 689 persons said that they never been tested for HIV, about 20% in the early debut
group and about 30 % in the later debut (p<0,001). OR for ever taken a HIV test was 1,5 [CI
1,2-2,0].
Table 6 Self-reported HIV status of MSM respondents in the internet-based crosssectional study, grouped by sexual debut:
Total
respondents
N (%)
Early
debut
N (%)
HIV positive
No
1655 (95,9)
281 (95,6)
Yes
71 (4,1)
13 (4,4)
Total
1726 (100,0)
294 (100,0)
HIV tested
No
689 (27,9)
80 (21,1)
Yes
1784 (72,1)
300 (78,9)
Total
2473 (100,0)
380 (100,)
*1
Ref group for univariate logistic regression analyses.
Later debut*
1
P-value
OR [95 % CI]
0,8
1,1 [0,6-2,0]
<0,001
1,5 [1,2-2,0]
N (%)
1372 (95,9)
58 (4,1)
1430 (100,0)
609 (29,1)
1482 (70,9)
2191 (100,0)
In those who had more than 500 lifetime partners 10,6 % was self-reported HIV positive.
Comparing 100≥ and 101≤ lifetime sexual partners with HIV status gave a higher proportion
of HIV+ in those with over 101 partners (p<0,000) (2,1% HIV + vs. 10,1% HIV +).
5.7 Alcohol
Alcohol use is described in table 7. The early debut group reports a higher usage of alcohol
than the later debut group. In those with an early debut 23,1 % reported feeling
“buzzed/intoxicated” more than 7 times last month, 16,7 % in the later debut group (p=0,003).
Likewise in the later debut group 38,4 % reported feeling “buzzed/intoxicated” once or less a
month, 31,5 % in the early debut group (p=0,01). The early debut group had a higher odds for
reporting that alcohol affected their physical OR = 1,8 [CI 1,4-2,3] and mental OR= 1,9 [CI
1,5-2,4] health. A higher percentage of the early debut group wished to reduce their drinking
(p=0,002). The early debut group had an OR= 1,8 [CI 1,4-2,3] for unprotected sex while
alcohol affected.
Page 15 of 25
Table 7 Associations between alcohol use and sexual debut age for MSM respondents in
an internet-based cross-sectional study, divided by sexual debut:
Total
respondents
N (%)
Early
debut
N (%)
Later debut*
1
P-value
OR [95 % CI]
<0,003
1,5 [1,1-1,9]
<0,000
1,8 [1,4-2,3]
<0,000
1,9 [1,5-2,4]
<0,002
1,6 [1,2-2,1]
<0,000
1,8 [1,4-2,3]
N (%)
1
Alcohol use* ,
monthly:
16 times or more
78 (3,0)
13 (3,4)
11-15 times
96(3,7)
18(4,7)
7-10 times
264 (10,3)
57(15,0)
4-6 times
506 (19,7)
93(24,4)
2-3 times
603 (23,4)
80(21,0)
About once
424 (16,5)
51(1,4)
None, or less than
497 (19,3)
69(18,1)
once
Total:
2489 (100,0)
383(100,0)
1
Alcohol use*
7 times or more a
month
No
2030 (82,3)
293 (76,9)
Yes
438 (17,7)
88 (23,1)
Total:
2468 (100,0)
381 (100,0)
Alcohol affected
physical health
No
1904 (78,3)
257 (69,1)
Yes
527 (21,7)
115 (30,9)
Total
2431 (100,0)
372(100,0)
Alcohol affected
mental health
No
1992(81,8)
272 (72,7)
Yes
442 (18,2)
102 (27,3)
Total
2432 (100,0)
374 (100,0)
Wish to reduce
drinking
No
2237 (86,9)
312 ( 81,5)
Yes
336 (13,1)
71 (18,5)
Total
2573 (100,0)
383 (100,0)
UAI while alcohol
affected
No
1773 (73,1)
233 (62,6)
Yes
651 (26,9)
139 (37,4)
Total
2424 (100,0)
372 (100,0)
*1
Ref group for univariate logistic regression analyses.
*2 Drinking until feeling intoxicated.
65 (3,1)
78 (3,7)
206 (9,9)
413 (19,8)
523 (25,1)
373 (17,9)
427 (20,5)
2106 (100,0)
1736 (83,3)
349 (16,7)
2085 (100,0)
1646 (80,0)
411 (20,0)
2057 (100,0)
1719 (83,6)
339 (16,5)
2058 (100,0)
1842 (87,5)
264 (12,5)
2106 (100,0)
1539 (75,1)
511 ( 24,9)
2050 (100,0)
Page 16 of 25
5.8 Drug use last 12 months
The participants were asked about their use of marihuana/hash, pharmaceuticals, ecstasy
(XTC), LSD, GHB, cocaine, heroin, amphetamine, methamphetamine, “poppers” and Viagra.
An association between an early debut and all the drugs above was found. The lowest OR was
found for “poppers” OR = 1,4 [CI 1,1 – 1,8], and the highest for methamphetamine OR = 4,4
[CI: 2,2-8,8] (table 8).
The most common used drugs are marihuana/hash, cocaine, amphetamine, “poppers” and
Viagra. The early debut group as well had a higher usage of some of the drugs. Having tried
hash/marihuana more than 11 times OR=2,1 [CI 1,3-3,3].
The following percentages are for usage more than 10 times in the early debut group: 3,2 %
cocaine, 3,5 % amphetamine, XTC 0,8%, LSD 0,5%, GHB 1,1%, heroin 0,5%,
methamphetamine 1,1 %. There percentages are about double the percentages for the later
debut group.
Out of the 595 who had tried marihuana/hash, 198 had tried it before sex, about 30 % in both
groups (p=0,1). 198 had tried cocaine, and 65 of those had tried it before sex (p=0,6).
41,9% (early debut) of those who had tried amphetamine, did it in context of sex, compared to
49,5 % in those with a later debut (p=0,4). 79,1 % of those who had tried poppers, used it in
context of sex, compared to 87,9% in those with a later debut (p=0,01).
Page 17 of 25
Table 8 Associations between drug use last 12 months and sexual debut age for MSM
respondents in an internet-based cross-sectional study, grouped by sexual debut:
Total
respondents
N (%)
Early
debut
N (%)
Tried marihuana/hash
No
1857 (75,7)
252 (66,7)
Yes
596 (24,3)
126(33,3)
Total
2453 (100,0)
378(100,0)
High on
pharmaceuticals
No
2275 (93,2)
332 (88,3)
Yes
166 (6,8)
44 (11,7)
Total
2441 (100,0)
376(100,0)
Tried GHB
No
2382 (97,3)
355 (94,2)
Yes
67 (2,7)
22 (5,8)
Total
2449 (100,0)
377(100,0)
2
Tried XTC*
No
2347 (96,2)
349 (93,1)
Yes
93 (3,6)
26 (6,9)
Total
2440 (100,0)
375(100,0)
Tried LSD
No
2420 (99,3)
367 (98,4)
Yes
16 (0,7)
6 (1,6)
Total
2436 (100,0)
373(100,0)
Tried Cocaine
No
2244 (91,9)
331 (88,3)
Yes
198 (8,1)
44 (11,7)
Total
2442 (100,0)
375 (100,0)
Tried Heroine
No
2419 (99,1)
368 (97,9)
Yes
21 (0,9)
8 (2,1)
Total
2440 (100,0)
376 (100,0)
Tried Amphetamine
No
2291(93,9)
332 (88,5)
Yes
148(6,1)
43 (11,5)
Total
2439(100,0)
375 (100,0)
Tried
Methamphetamine
No
2393 (98,6)
360 (96,0)
Yes
34 (1,4)
15 (4,0)
Total
2427 (100,0)
375 (100,0)
Tried “Poppers”
No
1770 (72,3)
249 (65,9)
Yes
678 (27,7)
129 (34,1)
Total
2448 (100,0)
378 (100,0)
Tried Viagra
No
2155 (88,2)
314 (83,7)
Yes
289 (11,8)
61 (16,3)
Total
2444 (100,0)
375 (100,0)
*1
Ref group for univariate logistic regression analyses.
*2 XTC = Ecstasy
Later debut*
1
P-value
OR (95 % CI]
N (%)
<0,000
1,7 [1,3-2,2]
<0,000
2,1 [2,5- 3,0]
<0,000
2,8 [1,6-4,7]
<0,001
2,2 [1,4-3,5]
<0,02
3,3 [1,2-9,3]
<0,006
1,6 [1,2-2,3]
<0,007
3,4 [1,4-8,3]
<0,000
2,4 [1,7-3,5]
<0,000
4,4 [2,2-8,8]
<0,002
1,4 [1,1-1,8]
<0,004
1,6 [1,1-3,2]
1603 (77,3)
470 (22,7)
2073 (100,0)
1941 (94,1)
122 (5,9)
2063 (100,0)
2025 (97,8)
45 (2,2)
2070(100,0)
1996 (96,8)
67 (3,2)
2063(100,0)
2051 (99,5)
10(0,5)
2061(100,0)
1911 (92,5)
154 (7,5)
2065 (100,0)
2049 (99,4)
13 (0,6)
2062 (100,0)
1957 (94,9)
105 (5,1)
2062 (100,0)
2031 (99,1)
19(0,9)
2050 (100,0)
1520 (73,5)
548(26,5)
2068 (100,0)
1839 (89,0)
228 (11,0)
2067 (100,0)
Page 18 of 25
6.0 Discussion
Mean age among the participants was 32,4 years. Most of the participants live in Norway,
where about half lives in or around Oslo. 93 % count their cultural background as Norwegian.
50 % lives alone. Half the population has a higher education, compared to about 30 % in the
general population in 2011. 70 % is employed, compared to 63 % in the general population
(22). A large part has a high income (over 500 000 NOK). Thus it seems like the participants
represent a highly educated part of the society.
Sexual debut and sexual orientation
The median sexual debut in this survey was 17 years. There are few Norwegian data on this
theme. The Norwegian report on sexual behaviour of 2002, had a mean of 15 years for MSM
The median sexual debut age for heterosexuals was 17,5 for men and 17,1 years for women in
2002, respondents was between 18 and 22 years old (2). Thus there seems like the mean
sexual debut age in our survey is quite similar to the heterosexual Norwegian population of
2002. A Swiss study finds a median age at fist anal intercourse of 21 years (13). An
Australian study finds a median AFAI of 35 years for men born between 1944 1953 (oldest
age cohort) and 18 years for men born between 1984 and 1993 (youngest age cohort) (10).
In a Scandinavian study on young age at first intercourse and risk taking behaviours in women
11,6 % had an early debut (defined as 14 years or younger) (23), compared to 15,4% in our
results (with a lower age defined as early debut). Three of four state their sexual orientation as
homosexual and approximately one forth define themselves as bisexual (or uncertain), no
differences was found on sexual orientation and sexual debut in this study.
Education, income and employment
The early sexual debut group seems to be less educated compared to the later sexual debut
group, with a higher part of persons who have not completed more than primary school. A
Swedish study associates an early debut (in teenagers) with less positive school experiences
(4). There was slightly no difference in income. Though the percentage of employed persons
was similar, there was a difference in students/military/civil service and unemployed/socialsecurity/retired persons. An early debut was associated with being in
unemployed/retired/social-security takers. The later debut group had a higher percentage of
students.
Page 19 of 25
Sexual behaviour
In the Norwegian report on sexual behaviour of 2002 median number of sexual partners for
single men was 7, median 6 for single women. Median among those living with a partner was
6 for men, 4 for women. 33,4 % of single men had more than 11 lifetime partners, 27,1 % in
single women (2). Our result shows a higher number of life-time sexual partners for both the
group with an early debut and that with a later. The early debut group has almost three times
as many participants with more than 11 lifetime partners compared to the general population.
An American study finds more lifetime partners among gay and bisexual male youths (in New
York) compare to the heterosexual youths, and a mean number of lifetime partners of 17,6
compared to 5,5 (among the heterosexual youth population) (24). A Scandinavian study on
young age at first intercourse and risk-taking behaviours in women found that the adjusted
OR of reporting more than 10 lifetime sexual partners was almost 4 times higher among those
with an early debut (14 years and younger) than those with a later debut (15 years and older)
(23).
We found an association between an early debut and unprotected anal intercourse (UAI) with
a casual partner, but not with an anonymous partner. An anonymous partner meaning
someone you don’t know the identity of, and a casual partner meaning that you know the
person (but don’t have a steady relationship with). One might think that having UAI with a
partner you don’t know is taking a higher risk then with a casual partner. A Swiss study found
a positively and linearly association between age at fist anal intercourse and condom use, with
a higher probability of unprotected intercourse with a younger age at first anal intercourse
(13).
HIV
Other studies have reported an association between an early sexual debut and HIV infection
(10). There are 71 self-reported HIV positives in this survey, about 4 % of those who gave an
answer. No significant differences between HIV status and sexual debut age were found.
About 30 % in our study has never take a HIV test, thus it seems like a large part of this highrisk population doesn’t know their HIV status. Similar results is found in another Norwegian
survey, where more than a third never received the answer for a HIV test (25). 9 MSM got the
HIV diagnosis at the same time as their AIDS diagnosis in 2012, and 14 had an advanced HIV
Page 20 of 25
infection when they were tested for HIV. This means that probably more MSM in Norway has
an undiagnosed HIV infection, and that increased information on testing is needed (15).
We found an association between self-reported HIV prevalence and life time sexual partners,
with an increasing prevalence of HIV with numbers of sexual partners. Similar results are
reported in other studies (19). Though the early debut group has a higher number of lifetime
sexual partners, there was not found any association with HIV status. Participants in the early
sexual debut group seem to HIV-test themselves more than the later debut group. Good
insight of their increased risk for infection with numerous sex- partners and a lower threshold
for HIV testing can be an explanation that no difference was found on sexual debut and HIV
status.
Alcohol and drugs
Those with an early debut have fewer with a low alcohol consumption and a higher
percentage of high consumers compared to those with a later debut. Several studies report a
high prevalence of drugs and alcohol use among the MSM population (7, 26). Woolf and
Maistro reported a possible association between heavy episodic drinking among MSM and
sexual risk behaviour (26). Early intercourse debut may also be a pattern of problem
behaviour, wherein alcohol intoxication is an important predictor for both genders (27). There
are more participants in the early debut group that feel their mental and physical health is
influenced by their alcohol consumption, and more of them want to reduce their drinking.
This is an expected result since there is a higher usage of alcohol in this group.
Though the early debut group had significantly higher odds for trying the drugs implemented
in this study, some of the sub-groups are quite small. One of the most common tried drugs
(marihuana/hash) was also the one with the lowest odds ratio, meaning that marihuana/hash is
quite common in both groups. There may be a minor part of the early debut group that has a
much higher drug use compared to the others, this might be an interesting sub-group for
further research.
An American study find an association between drug and alcohol use and high-risk sexual
behaviour among MSM, with the thesis that it may help men to avoid feelings of anxiety
associated with same-sex behaviour and self-awareness of HIV risk (7). Several of the drugs
included in our study were commonly used in context of sex, though there was no difference
Page 21 of 25
between the sexual debut groups. Using drugs was highly associated with an early sexual
debut.
Though most respondents perceive their health as good or decent, those with an early debut
have as well a higher part that perceive their health as poor or decent, compared to a higher
part that perceive their health as good in those with a later debut.
Study limitation
Results from this study cannot be generalized or transferred from this population to the
general MSM population in Norway. Internet-based surveys may provide an easy and low
cost tool to reach a part of the MSM population. Those who use the internet to seek for sex
seems to have increased levels of high risk sexual behaviour and sexually transmitted
infections (28). Result from this study thus describes those of the MSM population that uses
internet for sex seeking behaviour.
In the sexual debut age question, the lowest possible answer was 10 years. Knowing that
sexual relations between older men and young boys are common in such communities, they
probably should have been able to submit younger age at debut. We thus are assuming that if
there were any with a younger debut, they have probably answered 10 years. Other studies
report that many young MSM had their sexual debut with an older adult man, bringing into
question the voluntary nature of the experience, which could be interesting for future studies.
For alcohol consumption the question was on feeling intoxicated. This is a very subjective
description, and one can assume that the relative amount of beverage would differ a lot
between respondents. It might have been useful to ask more specific about amounts to
determine specific usage.
Multiple responses were possible, but were unlikely as it took about 40 minutes to complete
the questionnaire.
There was a great age difference in the population and possible recall bias may exist,
especially among the older participants.
Some of the participants have answered yes to use of heroine, and thus the usage of
intravenous drugs are possible. HIV infected in this survey could therefore have obtained their
infection by intravenous drug use or heterosexual intercourse.
In this 5th year assignment (due to limited time) the analyses are limited to univariate logistic
regression.
Page 22 of 25
In conclusion, though the MSM respondents in this internet survey are more educated than the
general population, an increased risk of being under-educated and unemployed/retired/socialsecurity taker was found in the early sexual debut group. We also found an association with
numerous sexual partners, unprotected anal intercourse, and usage of alcohol and drugs in this
group. Our results show an association between an early sexual debut and a poorer health
outcome among MSM in this Norwegian internet study.
Page 23 of 25
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